The Appearance of Xylazine in the United States as a Fentanyl Adulterant.

Importance: Use of xylazine in the United States as an adulterant for drugs of abuse has increased in recent years, thus it is important for health care providers to understand the basic pharmacology and toxidrome of the drug, as well as management options for patients who have overdosed.Observations: Data obtained from studies between 2006 and 2022 indicate a rapidly increasing incidence of xylazine overdose in the United States, with overdose cases now being seen in 25 states. Hallmark symptoms of xylazine overdose include respiratory depression, bradycardia, hyperglycemia, central nervous system depression, and initial hypertension turning to unstable blood pressure. Xylazine overdose is not reversible with naloxone and requires supportive measures.Conclusions and Relevance: It is important for health care providers to be aware of presenting symptoms in xylazine overdose so that proper care can be provided. Facilities may consider adding xylazine to their routine toxicology report to aid in patient management and better assess the incidence of xylazine use as an adulterant in a given geographic area.Prim Care Companion CNS Disord 2023;25(6):22nr03473. Author affiliations are listed at the end of this article.

A Pediatric Patient with Severe Obstructive Sleep Apnea and Comorbid Depression and Substance Abuse.

Obstructive sleep apnea (OSA), depression, and substance abuse problems share similar symptomatology and have significant interplay. An underlying diagnosis of OSA can often be overlooked in patients with significant psychiatric illness and polysubstance use. Pediatric OSA is often associated with adenotonsillar hypertrophy and frequently requires surgical intervention for resolution of symptoms. Untreated OSA can worsen mental status and encourage polysubstance abuse as a form of self-medication. Proper identification and management of OSA plays an important role in treating psychiatric conditions. We report a 16-year-old with major depressive disorder (MDD), suicide attempts, polysubstance use disorder, and severe OSA admitted to an inpatient psychiatric facility. History included sleep and mood disturbances started at age 12. Patient presented with apnea-hypopnea index greater than 50 and started on bilevel-positive airway pressure (BiPAP) prior to admission. Management of OSA led to significant improvement of MDD, insomnia, and polysubstance abuse. OSA can often be overlooked in patients with MDD or substance abuse. Among adolescent patients with poorly managed psychiatric conditions, significant sleep disturbances, and polysubstance abuse, providers should maintain a high degree of suspicion for OSA, as its proper management will aid in the management of the other conditions.